[Digital ischaemia and gemcitabine. Two new cases]

Chemotherapy generates numerous adverse effects, but digital ischemia is usually associated with a paraneoplastic mechanism. In addition to thrombotic microangiopathy or hepatic or pulmonary venoocclusive disease gemcitabine appears to induce this type of complication. This study presents two cases of digital ischemia, which are very likely attributable to gemcitabine. The first case involved a 56-year-old female patient with lymph node metastatic squamous cell carcinoma, for which no primitive tumor could be identified. This carcinoma had been treated at a second stage with gemcitabine at a cumulative dose of 14 390 mg. Search for etiology revealed toxic vascularitis. Response was favourable after interruption of gemcitabine and prescription of a suitable medical treatment. The second case was a 74-year-old male patient with an infiltrating bladder urothelium carcinoma with lymph node metastasis. He had been treated by surgery and chemotherapy (gemcitabine and carboplatine). Gemcitabine-induced arterial thrombosis was diagnosed. Nine other cases of digital ischemia were identified in the literature. This rare adverse effect is probably underestimated. The other reported vascular side-effects are thrombotic microangiopathy, with an estimated occurrence of 1 per 6,000 patients and two cases of veno-occlusive disease. The pathogenic mechanisms have still not been fully elucidated. Precautions before use are necessary, especially in case of associated micro or macroangiopathy.

Syndrome de Sneddon avec anticorps anti-mitochondries de type M5

INTRODUCTION

Antimitochondrial type M5 antibodies (AMA-M5) are among the immunological abnormalities associated with Sneddon syndrome.

CASE

A 45 year-old woman, hospitalized for diplopia and with a 20-year history of obstetrical accidents, internuclear ophthalmoplegia and livedo, was diagnosed with Sneddon syndrome associated with primary antiphospholipid syndrome (APS) aggravated by the presence of AMA-M5.

DISCUSSION

AMA-M5 are immunological markers of APS to the same extent as antiphospholipid antibodies. This case demonstrates the interest of screening for AMA-M5 in cases of strong clinical suspicion of APS when the anticoagulant lupus test is normal and no anti-cardiolipin, anti-b2 glycoprotein I or antiprothrombin antibodies are found.

[Chronic meningitis: aetiologies, diagnosis and treatment]

PURPOSE

Chronic meningitis are very uncommon and account for less than 10% of all meningitis cases. Their symptoms are uncunth and there outcome is insidious. Therefore, they remain often unknown. There are only a few published reports on this disease, so diagnosis and therapeutic approachs are difficult.

CURRENT KNOWLEDGE AND KEY POINTS

Positive chronic meningitis diagnosis is easy. However, determining the cause of chronic meningitis remains dilemma, as many infectious and noninfectious processes (including inflammatory, neoplastic or autoimmune aetiologies or as a result of a chemical exposure) can result in the chronic meningitis syndrome. In order to institute a pertinent treatment, sometimes urgently needed, diagnostic approach must be extremely rigourous and accutely orientated. Nevertheless, although extensive investigations, 30% of the aetiologies remain undetermined. Only two choices are left for the medical physician: an aggressive attitude based on complementary investigations or a contemplated therapy with a close clinical and biological control. On the other hand, when the patient's condition is quickly deterioring without a clear and proved aetiology, it is sometimes necessary to institute an empirical treatment, not always properly determined and sometimes contreversial. Besides, few reports on prognosis and outcome od idiopathic chronic meningitis have been published.

FUTURE PROSPECTS AND PROJECTS

After a review of aetiologies and diagnostic investigations chronic meningitis, we propose a practical experience attitude about management and treatment of chronic meningitis. Thus, large-scale studies about the follow up chronic meningitis in long term, in particular those without aetiology, treated or no, should improve the outcome of this chronic syndrome.

High prevalence of hepatitis C virus RNA in the supernatant and the cryoprecipitate of patients with essential and secondary type II mixed cryoglobulinemia

Detection of hepatitis C virus RNA by polymerase chain reaction was performed in 26 patients with type II mixed cryoglobulinemia, and compared with anti-HCV antibody detection. The patients were divided into two groups according to etiology: 15 had essential type II mixed cryoglobulinemia and 11 had secondary type II mixed cryoglobulinemia. In the essential type II mixed cryoglobulinemia group, the prevalence of hepatitis C virus RNA detected by polymerase chain reaction was 60% in the supernatant and 93% in the cryoprecipitate. In the secondary type II mixed cryoglobulinemia group the prevalence of hepatitis C virus RNA was 45% in the supernatant and 55% in the cryoprecipitate. The differences between the two groups were not statistically significant. In both patient groups, detection of hepatitis C virus RNA in the cryoprecipitate was the most sensitive test for hepatitis C virus infection. These results suggest that hepatitis C virus might be involved in the origin of mixed cryoglobulinemia.

[Evaluation of the importance of ambulatory blood pressure measurement in the diagnostic and therapeutic management of hypertension]

PURPOSE

evaluate, in a Public Health approach, the contribution of ambulatory blood pressure recordings (ABPR) in the diagnostic and therapeutic management of hypertension.

METHODS

a retrospective study is led among 32 physicians who have addressed 473 patients for ABP: 182 for borderline hypertension (B-H) diagnosis, 94 for treatment decision (NT-H) and 197 for a therapy efficiency assessment (T-H). ABPR is performed with the non invasive Spacelabs device on a 24 hour period. The data interpretation is provided by statistical comparison of patient's data with those of a same age and sex 30 normotensive subjects group.

RESULTS

The table presents the action of physician according to the ABPR motive and answer: TT = therapy, NT = no therapy, ADJ = adjustment, NADJ = no adjustment. (Table: see text).

CONCLUSION

physicians follow drastically ABPR interpretation: a large number of patient avoid a treatment (68 percent of B-H group and 63 percent of NT-H group), the therapy is modified for 40 percent of the T-H patients. Such evidence may have some Public Health implications.

[Does the blood pressure balance obtained in hospitalized hypertensive patients remain satisfactory a month later at home? (Ambulatory measurement)]

Twenty patients with hypertensive heart disease have been hospitalised for adjustment of their antihypertensive medication. The new treatment was left unchanged during a period of forty days, the survey consisted in three blood pressure measurements at rest every day during the first ten days of hospitalisation and an ambulatory blood pressure measurement the 10th and 40th day. The 10th day, there is no significant correlation between blood pressures measured at rest and ambulatory, even if the average BP levels are not significantly different. The 40th day, the average BP levels are equivalent with a correlation coefficient of 0.5 for the systolic and 0.64 for the diastolic blood pressure (p less than 0.01). Thus, a measurement of the ambulatory BP at the 10th day of hospitalisation seems to be a good indicator of the expected long term therapeutic effect. However, absence of greater increase of the ambulatory BP at one month probably corresponds with the majored action of certain treatments as time goes by.

Chronic trichloroethylene intoxication: a new approach by trigeminal-evoked potentials?

Trigeminal nerve impairment is frequently seen in chronic trichlorethylene intoxication (TRI). A total of 104 occupationally exposed subjects were selected for study because they were employed at a highly exposed workplace. They were studied by clinical examination and by trigeminal somatosensory evoked potentials (TSEP). Normal values for TSEP were obtained from the study of 52 healthy nonexposed subjects. Facial hypoesthesia, when present, was global and predominant in the mandibular and maxillary nerve areas, associated or not with absent reflexes. A disturbed TSEP was found in 40 subjects which was predictable from their clinical symptoms. Correlation with exposure parameters (duration of exposure, trichlorethanol, and trichloracetic acid urinary rates) was mainly observed in subjects presenting both clinical and electrical alterations. Electrical alterations alone were less predictive. An abnormal TSEP may thus provide objective determination of risk assessment in the absence of clinical signs.

Determination of beta-endorphin in alcoholic patients in the acute stage of intoxication: relation with naloxone therapy

beta-Endorphin was measured in the plasma of control subjects and 12 chronic alcoholics in the acute stage of ethanol intoxication. Naloxone was administered and the level of beta-endorphin was compared before and after treatment. The increased level of beta-endorphin in the intoxicated subjects supports the presence of ethanol interactions with the opioid system, since pituitary secretion does not seem to be involved. Furthermore, the coexistence of high levels of beta-endorphin and an effective naloxone response suggest a possible link between the two.

[Personality characteristics of hypertensive patients. Study of subjects with essential hypertension compared to a control population]

Starting from projective situations--thematic apperception test (TAT) we have researched personality characteristics liable to be found in hypertensive subjects. With reference to a control group of 59 subjects we have studied 41 essential hypertensive subjects. They undergo a preliminary interview structured on the questionnaire type, are classically tested with the TAT, have one or several free interviews. These data are exploited on three levels and contents = manifest, latent, adaptive. It emerges that there are permanent biographical elements (elements of reactivation. Difficulty to put up with aggressiveness, object loss anxiety, use of operative thought back of adaptation = absence of solution to conflicts and possibilities of passage ?), personality patterns in between obsessional pole neurosis and limit state (Bergeret's nosography). These data partly overlap other research, they encompass a wider field than hypertension, given the structures involved (limit state, psychosomatic component). The lack of mentalization justifies the use of therapeutic techniques such as relaxation, biofeedback...

[Ambulatory measurement of arterial pressure. Diagnostic, prognostic and therapeutic value]

The invasive and non-invasive techniques now available for automatic monitoring of blood pressure have provided new sets of physiological as well as diagnostic and therapeutic data. Recordings of blood pressure variations over a 24-hour period have shown that it increases during the day and decreases at night, that these physiological changes are more pronounced in the elderly than in young subjects and also that they depend on the degree of physical activity. The clinical applications of these techniques rest on the possibility of recording a blood pressure-activity profile over time, in order to speak, ultimately, in terms of blood pressure load activity. By reference to a normal blood pressure profile, genuinely hypertensive subjects can be differentiated better from those overactive, hyperemotional subjects who are perhaps not suffering from true hypertension. Finally, 24-hour recordings repeated over periods of several days or weeks enable the clinicians to assess therapeutic effectiveness and to envisage an authentic chronotherapy.

[Changes in sweating during exertion. Effects of beta-blocker treatment]

Eccrine sweat secretion is studied during physical stress after the administration of a B-blocking agent: Butofilolol. 20 voluntary normotensive subjects, age 24 + 2 ans are submitted to 2 exercises stress test (ergometric bicycle) performed at on week interval. Butofilolol is administrated at a posology of 200 mg, 24 hours and 2 hours, before the test as well as placebo (double blind). Local sweat output is measured 1 min after stress and in the interscapulary region with an evaporimeter. Sweat weight, sweat electrolyte concentrations (sodium, chloride) are analysed from filters papers placed on the forehead. With butofilolol, significative increases of sweet output (+13%), sweat weight (+20%), and sodium (+20%), chloride (+26%) elimination are observed. The subjective observation of the effects of B-blocking agents is confirmed. The way of action of Butofilolol discussed.

[Data on the echocardiogram, pressure profile during exertion, and ambulatory blood pressure measurements in borderline arterial hypertension]

Comparative study is performed between echocardiographic measurements (TM), exercise test blood pressure profile (ETP) and ambulatory blood pressure load (BPL) in 26 borderline hypertensive subjects (19 males, 7 females). An abnormal ETP is found for 15 subjects (57 p. 100), an abnormal BPL for 10 subjects (38 p. 100). The diastolic interventricular septum thickness (IVS) and the diastolic posterior wall thickness (PWT) are abnormal (greater than 11 mm) for 6 and 3 subjects. Patient with pathologic ETP or/and BPL have greater IVS and PWT than other subjects (p less than 0,001). A good correlation is found between individual activity systolic blood pressure or 24 hours systolic blood pressure means values and PWT, IVS or left ventricular mass. These 3 examinations lead to a better assessment of cardiovascular strain and allow a better diagnosis and therapeutic approach in borderline hypertensive patients.

Trichloroethylene occupational exposure: elements for better prevention

One hundred and eighty-eight workers occupationally exposed to trichloroethylene (TRI) were studied by physical examination, exposure parameters (measure of atmospheric TRI and urinary trichloroacetic acid (CA) and evaluation of personal factors (age, alcoholic and tobacco consumption). A statistical comparison (chi 2 test) of the frequency of the symptoms observed in the high- and low-exposure populations with an analysis of nonprofessional factors allowed us to distinguish different classes of symptoms. Those more likely linked with TRI exposure are trigeminal and optic nerve impairment, asthenia, headache and dizziness. An interaction between TRI exposure and alcohol intake on the occurrence of clinical liver impairment and degreaser flush is suggested.

Internuclear ophthalmoplegia in patients with toxic coma frequency, prognostic value, diagnostic significance

Internuclear Ophthalmoplegia (INO), a dysfunction of the medial longitudinal fasciculus, is frequently seen in toxic coma (7 out of 70 cases). INO is most often bilateral and can be associated with different stages of coma. Such an association is a strong argument for the toxic etiology of a coma. But INO has no value in determining the source of intoxication and is no prognostic indicator for the outcome.

[Ambulatory measurement of arterial pressure by a noninvasive procedure. Study of its variability in 18 normotensive subjects and 25 hypertensive patients. Research on criteria of normality]

Ambulatory blood pressure monitoring by an automatic non-invasive procedure allows the measurement of a large number of blood pressures and provides information in the variations of blood pressure during normal activity. The development of a programme on a minicomputer has helped simplify the expression of the results by: --a graphical representation of the evaluation of the blood pressure with respect to time (chronogramme); --a histogramme showing the distribution of the blood pressure values; --a representation of the pressure load with respect to time. By stocking the individual results a statistical study could be undertaken of the whole population. Eighteen normotensives, 15 borderline hypertensives and 12 permanent hypertensives were monitored for 24 hours. A circadien variation of blood pressure was observed in all three groups. Over an arbitrary chosen period (9 am-9 pm) the mean blood pressures and heart rates were: --Normotensives: SBP = 134 +/- 19; DBP = 79 +/- 11; HR = 79 +/- 14; --Borderline hypertensives: SBP = 151 +/- 30; DBP = 90 +/- 16; HR = 86 +/- 18; --Permanent hypertensives: SBP = 157 +/- 27; DBP = 102 +/- 17; HR = 83 +/- 17. An interpretation of these results requires information about the normality of the blood pressure levels during normal activities which remains to be studied. Resting values measured in the doctor's surgery need to be compared to ambulatory values in these three groups in order to judge the real significance of this method of measurement, and, in particular, to determine if the resting values are predictive of the blood pressure levels during activity.

[Changes in heart rate and blood pressure in a series of normotensive subjects before and after beta-blocker treatment (double-blind) during physical, dynamic, static and psychosensorial stress]

23 normotensive subjects in good health are submitted to a "test de l'exposé" and 17 others are submitted to a test on an ergometric bicycle and a hand grip stress test. These tests are performed twice at one week interval, with or without treatment with acebutolol, in double blind. HR,SBP and DBP are measured simultaneously before, during and after each test. Every stress is responsible for a marked increase in the parameters according to different modalities. With ACEBUTOLOL treatment, during the test described and during dynamic stress on ergometric bicycle, HR and SBP are always less elevated. The decreases are dependent either on the stress level or on the reactivity of the subjects. DBP is however basely modified. Under static stress, there is a decrease in HR, in SBP, but also in DBP; actually increase in this parameter is important during this type of stress.

[Value of the study of trigeminal nerve evoked potentials in chronic trichloroethylene poisoning. Preliminary results]

Results of a study concerning the trigeminal nerve impairment as the one caused by trichlorethylene chronic intoxication by somatosensory evoked potential reveal three kinds of anomalies: increase of the stimulation voltage, excessive latency delay with morphological anomalies and excessive graph amplitude. These anomalies confirm clinical disturbance (hypoesthesia in the trigeminal area) and open a debate about the real mechanism of the trichlorethylene neurotoxicity.

[Automatic measure of arterial pressure using the oscillometric method (Dynamap 845)]

The reproducibility and reliability of measurements performed with an automatic blood pressure measuring device based on the oscillometric method were assessed by comparison with the results obtained by the indirect auscultation using a mercury manometer. The results of the mean values, of the correlation between successive values and of the variation of the values of systolic and diastolic blood pressure show that the readings obtained by the automatic method are very reproducible.

[Data from a study of variations of arterial pressure during exercise in boys aged 11 to 16]

Systolic, diastolic BP and heart rate were measured in 106 boys aged between 11 and 16 years old, at rest and during exercise on a bicycle ergometer. The results show: -- at rest: an increase in systolic and diastolic BP with age, and a decrease in heart rate; -- during exercise: an increase in systolic BP without an increase, or with a decrease in diastolic BP. The blood pressure readings were higher in overweight and post pubertal subjects. The value of this study lies in the high number of reproducible readings obtained and in the suppression of the effects of emotivity. It completes the observations made at rest in subjects suspected of having hypertension.

[Physiological variations of arterial pressure and heart rate in the first 5 minutes after moving from a supine to an upright position]

The physiological variations of blood pressure and heart rate were studied in the first five minutes of orthostatism in conditions identical to those encountered in clinical medicine. An increase in heart rate and diastolic blood pressure was observed from the first minute. The value of systolic blood pressure decreased as the subject got up and then rose to the value measured when lying down. At the fourth and fifth minute the three parameters were stable at significantly higher values than observed when lying down for the heart rate and diastolic blood pressure, but at an identical level for the systolic blood pressure. This study shows the necessity of measuring the orthostatic blood pressure using a precise technique which detects postural abnormalities when measured in the minute of orthostatism and which gives an assessment of the standing blood pressure when measured at the fifth minute.

[Evaluation of an automatic device for arterial blood pressure determination : the Arteriosonde 1217]

The reproductibility and reliability of measurements made with an automatic device for measuring blood pressure was assessed with reference to the results obtained by indirect auscultation with a mercury manometer. The results of the study of the average values of the correlation between successive values, and of the variability of the values of the systolic and diastolic blood pressure show that the measurement obtained by this method are very reproducible.

[Role of extracorporeal surgery in the treatment of severe lesions of the renal artery and its branches]

This method has been used with good results in three patients, two of whom had single kidneys.

[Value of continous 12-hour electrocardiography during the rehabilitation period in patients convalescing from myocardial infarction. Apropos of 40 cases]

The results of continuous 12-hour electrocardiography in 40 convalescent patients after myocardial infarction undergoing a programme of readaptation on average 4 weeks after the initial infarction are reported. The frequency and alarming nature of the VES observed in 75% patients who had already undergone selection for the coronary readaptation programme, 30% of whom were receiving antiarrhythmic therapy, is emphasized. The observation of a progressive increase in the number of VES during the day prompts the following suggestions: the possibility of limited continuous ECG monitoring at the end of the day, the need to adapt the dosage of antiarrhythmic drugs during this most critical period. The comparison of the results of continuous ECG with those of repeated exercise ECG seems very positive, but some reservations are made and it would seem logical to associate these two complementary methods of investigation.

[Reproducibility of measurements of arterial pressure and heart rate during exercise test: its significance and application]

The authors report their findings from a study of the reproductibility of measurements of blood pressure and heart rate both at rest and during exercise (work on a bicycle ergometer) in 19 patients who were tested on two occasions with a mean interval of 9.8 days. A study of the correlations, of variability, and of the findings on applying Student's "t" test, have led us to the conclusion that these parameters are more reproduceable on exercise than at rest, and become increasingly reproduceable as exercise increases. These conclusions support the use of an induced hypertension test under exercise.

Action of norepinephrine on the serum gastrin level

The authors have studied the influence of endogenous norepinephrine released during exercise on the level of serum gastrin. After a period of absolute rest, 10 volunteers in good health underwent a prolonged graded exercise corresponding to 60, then 80% of the maximum theoretical heart-beat frequency. Only norepinephrine was significantly high during the course of the second phase of muscular activity. No significant change in serum gastrin was observed during the entire test.

[Data from systematic electrocardiographic study during exercise in hypertensive patients. Apropos of 307 cases]

The authors report the data of a systematic electrocardiographic study of 307 subjects suffering from hypertension. They analyse the EKG anomalies at rest and after exercise and study the relationships likely to exist between these anomalies and other parameters such as age, blood pressure, etc. They stress the diagnostic but also discriminatory value of this type of investigation in hypertension.

[Test of provoked arterial hypertension. Value and limitations of the static exercise of prolonged handgrip]

The used of a test of prolonged grip and recording the changes in arterial blood-pressure and heart rate is suggested as a way of studing the blood-pressure changes of effort in hypertensives. This test provides a real screen for provoqued hypertension: it allows --to define a normal profile of reference for blood-pressure, --to check the fluctuations at rest of blood-pressure, --to determine the severity of haemodynamic dissorders, --to judge the efficiency of hypotensive therapy.

[Value of the study of the arterial pressure values under exercise in normotensive and hypertensive patients]

Study of the blood pressure and cardiac rate changes in the course of an exercise test makes it possible to assess the possibilities of cardiovascular adaptation. This "induced arterial hyperrtensive subjects from those who possibly are not, and to assess correctly the blood pressure changes observed in various circumstances. On effort, an approach of the severity of the haemodynamic disturbance of the consequences of this disturbance, of the efficiency of treatment.